Provider Demographics
NPI:1235707274
Name:SOMERVILLE, PAYTON
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:SOMERVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 CARVER BLUFFS PKWY
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-9516
Mailing Address - Country:US
Mailing Address - Phone:195-241-2294
Mailing Address - Fax:
Practice Address - Street 1:310 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3218
Practice Address - Country:US
Practice Address - Phone:612-223-8898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN68864104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker